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Full text of "Report of Colin G. Snider, Commissioner, in Inquiry Respecting Ontario Hospital, Hamilton"


ONTARIO 
DEPARTMENT OF THE SECRETARY AND REGISTRAR 




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COMMISSIOirSR'B REPOHT, 



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REPORT of COLIB G. SNIDER, Judge of the County 
Court of the County of Wentworth, appointed a Commissioner 
to enquire into, investigate and report upon the adminis- 
tration, management, conduct, discipline and welfare of 
the ONTARIO HOSPITAL, Hamilton. 

To His Honour the Lieutenant Governor in Council. 



Your Commissioner appointed by Royal 
Commission under the Seal of the Province of Ontario 
bearing date the twenty-second day of January in the year 
of Our Lord one thousand nine hundred and twenty to inves- 
tigate and report upon the matters hereinbefore mentioned 
with such recommenuations as your Commissioner may think 
desirable, having taken upon himself the burthen of the 
investigation reports as follows :- 

On the 11th day of February A. D. 1920 
the investigation was commenced at the Ontario Hospital, 
Hamilton, and it was finished on the 17th day of February 
A. D. 1920. Public notice was given in the Hamilton 
Spectator, the Hamilton Herald and the Hamilton Times, 
daily newspapers published in the City of Hamilton, call- 
ing attention to the issue of the Commission, its purpose 
and scope and to the time and place of holding the inves- 
tigation and calling on all persons having knowledge of c 
charges and matters to be investigated, or which ought 
to be investigated, to give information thereof to 
your Commissioner or to S. F. Washington K. C. appointed 
as Counsel to aid in the presentation and prosecution of 
all such charges and matters. 

Each charge, complaint and matter coming 



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within the scope of your Commissioner's authority and which 
was brought in any way to his notice was fully investigated, 

It is a matter of great satisfaction to 
your Commissioner to be able to report that no charge or 
complaint was made by any person against the Superintend- 
ent, or Assistant Superintenc ent, or against any of the 
physicians of the Ontario Hospital at Hamilton. Every 
inmate and witness who spoke of these officers said that 
they were always attentive -to the inmates and treated 
them with kindness and consideration. 

The same statement applies to the chief 
executive officers. 

From the evidence and from personal investiga- 
tion and observation which your Commissioner took the 
opportunity to make, he is satisfied that the administra- 
tion and management of this Hospital is good and worthy 
of the confidence of those who have or may have occasi&nn 
to have relatives or friends there. 

No charge of misconduct or improper conduct, 
other than violence towards patients, was made against any 
person engaged in any capacity in, or in connection with, 
this Ontario Hospital. 

There were many charges made and investigated 
alleging violent treatment of patients by certain named 
attendants and nurses, such as striking with the fist, 
slapping, kicking patients and dragging females along the 
floor by the hair. 

Your Commissioner is quite satisfied from the 
evidence of undoubtedly reliable male and female chief 

supervising officers and officials and other confirming 






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facts that such acts of violence towards patients have 
not been and are not at all of general or frequent occur- 
rence. There undoubtedly have been some occurrences 
of violence to patients and it could not reasonably be 
expected that among i_0 to GOattendants, selected from 
the general run of young men who seek such employment 
there would not be here and there one engaged who would 
in temper strike a patient who attacked him violently, 
striking or biting or trying to choke the attendant in 
the struggle to control the patient. 

The evidence shows that many insane patients 
are very violent, treacherous, sly in attacking other 
patients and the attendants. I t isthe duty of the 
attendants to prevent or. check these attacks among the 
patients, who must be together a great part of the day 
time, and to at once seize and remove and isolate the 
patient who has become violent. Ho serious injury was 
caused a patient by an attendant in any case. One atten- 
dant said he had seen twenty to thirty Rights start between 
patients in a day in Ward 8. (Refractory) 

The discipline of the employees appears 
satisfactory upon the whole and it was shewn by the evidence 
of complainants and witnesses that whenever a complaint 
has been made to the Superintendent or to the doctor in 
charge of a ward or other chief officer the matter of the 
complaint has been properly investigated and remedied. 
?or minor offences a fine is inflicted and for serious 
offences such as acts of unnecessary violence the offender 

is dismissed. Where this practice is properly and 
vigorously followed and enforced as it has been so far as 
the evidence shews, no better means of enforcing proper 



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discipline was suggested. 

I t must be remembered that a very considerable 
number of the most experienced and reliable attendants 
joined the Canadian Army and went rcerseas, and it was 
impossible during the continuance of the war, when so many 
of the best young Canadian men were Overseas, to secure 
from among those remaining at home substitute attendants 
who were all quite satisfactory. Several attendants 
who were taken on during this time had to be dismissed 
for drinking and for rough treatment of patients. 

At different times during the war there were 
not enough attendants obtainable to properly man the wards, 
and the nurses were and still are over twenty short of 
the number required. 

To enforce discipline among the attendants 
and nurses and to ensure the welfare of the patients there 
are three chief attendants between whom are divided all 
the male wards, a certain number being assigned to each. 
The three chief attendants are James Slater, there 35 
years,- Michael Dean, there 20 years, and Julius A. Halbhans, 
there 16 years. On the female wards, Margaret O'Donnell, 
superintendent of all nurses in the Hospital, returned to 
this Hospital after three years work of nursing wounded 
soldiers in the Military Hospitals in England and France, 
has been discharging her duties in this Ontario Hospital 
since 1910, excepting the three years spent with oujr Army 
Overseas,- Nurse Isabella LlcI.Iillan is head nurse over those 
in the main building,- ITurse Jane Aikins is acting chief 
attendant in rchard House, and ^rs. H. E. Robertson, a 
widow, is supervisor of nurses in Orchard house, the Infir- 
mary and the Shack, where she has been engaged for the 
past 16 years. 












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Helying on his experience in judging character and 
fitness from appearances, manner and examination, your 
Commissioner reports that he is of opinion that these Chief 
officers, both male and female, most of whom appeared before 
him, are well suited for their duties and are truly inter- 
ested in the proper discharge of their duties and the wel- 
fare of the patients. 

It was proved that all these Chief officers 
devote their whole attention to their work in and about the 
houses and wards under their respective care. Under these 
Chief officers there are, as far as they can be obtained, 
two or three attendants in each male ward and two or three 
nurses in each female ward, all on duty in their respective 
wards throughout the whole day. 

Each house has its own physician in charge 
of the wards in it, who makes one morning visit and inspec- 
tion of each ward under his care and of each inmate of it 
at a regular hour and at irregular hours through the day 
makes unexpected visits as his other duties to his sick 
inmates, etc., will permit. 

This staff has charge of some 1250 insane 
persons, a number of them insane criminals sent here from 
the penitentiary at Kingston and from other prisons and 
towns. A much larger number are refractory, treacherous, 
dangerous patients, who take advantage of an opportunity 
to pinch, kick, or knock down a fellow-patient or an atten- 
dant, and thus start trouble in the ward. 

Scenes of which the following is a sample 
are frerauent and shew the difficulties attendants are 
faced with and in the opinion of your Commissioner, when 



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viewed by patients looking on and in some cases taking part, 
are the foundation of many exaggerated charges that have 
been made. On one occasion at dinner in the dining-room, 
where the violent men, patients of Ward 8, the refractory 
17ard, were dining, a patient, whose name I need not mention, 
suddenly and without apparent cause struck the patient 
beside him in thenface with his fist a severe blow. This 
patient told me he was led to strike this man and others 
on many occasions by the stronger will of some person some- 
where entering into him q.nd suggesting to him that he should 
strike and in fact compelling him to do so for no reason 
that he knew of. The man who received the blow imme- 
diately started to fight his attacker. All became more or 
less excited and disturbed. Two of the attendants present 
had to take this man out at once to prevent a general 
fight among these excited and dangerous inmates, who armed 
with the dishes and glasses on the table could have done 
grave injury to each other. The other attendant tried to 
quiet those in the room. The man being removed fought, 
kicked, struck and did everything he could to resist being 
removed to his own room. The charge arising out of this 
incident is specially dealt with later in this report. 

^n further reference to the welfare of the 
patients inthis Hospital your Commissioner reports that 
one male and one female witness complained of the soup and 
of general shortage of food, medecines and medical supplies 
during the war. The man making these charges was an 
ex-attendant. As regards the soup, it was proved by the 
Chef, the attendants and patients now there, that the 
soup and other food has been and is good and this charge 
not true, that the attendants and other employees eat the 
same food and soup out of the same pot, etc., as the patients 



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are given, but it is true that in 1915 or 1916 an expert 
dietician, named Granger, was sent here by the Department 
and he ordered the food allowed to be cut down considerably, 
which was done until by order of the Department it was 
increased again. His evident exaggeration of events and 
his manner of giving his testimony gave the impression that 
this man's statements, which were contradicted by reliable 
witnesses, were to a certain extent animated by malice 
and an exaggerated idea of his ability to judge what mede- 
cines and dressings the various patients ought to have been 
given by the doctor in charge. The woman ex-patient, who 
condemned the food, did not attend. She was subpoenaed 
but said she would not come. 

Many specific charges of violent and cruel 
treatment of inmates were made by discharged patients against 
attendants in the wards for male patients and against nurses ■ 
inthe wards for females. Each complainant claimed to have 
seen or heard the occurrences they respectively describe. 

In the worst charges investigated the alleged 
acts of cruelty as they were described could only have been 
committed by men and women of the most brutal instincts and 
could not possibly have all been concealed from the chief 

officers. The extravagance which characterized the corn- 
evidence 
plainants of itself made their charges practically unbeliev- 
able. Any very satisfactory corroboration was lacking. 
Admittedly no report or complaint was made to a physician 
or the superintendent or any chief officer. The evidence 
of other v/itnesses contradict these stories. The doctors 
and chief officers swore that none of them ever heard of 

these brutal acts and some of them in each charge said under 
oath that such treatment of a patient could not possibly 



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have been given without it coming to their knowledge 
either from seeing it or from noticeable marks on the 
patient or in the rooms or by information given. 

These facts and the history, demeanour and 
appearance of the various witnesses when giving evidence, 
in the opinion of your Commissioner prove beyond reason- 
able doubt that these charges of extreme violence and 
cruelty ma&e against attendants and nurses are not true, 
but are the discharged patient's amplified memory of false 
impressions made on his disordered brain on seeing a 
demented, refractory and violently resisting fellow- 
patient fighting and struggling against being removed to 
his room from amongst the other patients or being compelled 
by force to undress or dress, to go to bed or get out of 
bed, to take food or take a bath, or do other necessary 
things against his strenuous resistance as at times had to 



be done. 



saying 
Complaints were received from patients that they 



were put in the Asylum, though perfectly sane. Your 

not 
Commissioner did investigate any of these, being of opinion 

that such cases do not come within the scope of the 

investigation. Your Commissioner would suggest that, 

hav|ng in mind the fact that persons are committed to this 

Hospital for the insane on the certificate of physicians 

who have not much, if any, experience in mental cases and 

mistakes may occasionally be made, arrangements should be 

made v/hereby an inmate who claims with any shew of reason 

that he is sane would be given promptly as a matter of 

right an examination by an expert in such cases and a 

report made on his case to the Department- 



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A further suggestion is that returned soldiers 

suffering from nervous disturbance due to their experience 

in 
and suffering A the war should not be sent to a Hospital 

for the Insane, as long as there is a chance of this trou- 
ble passing without the patient becoming actually insane. 
Some place quite apart from an asylum should be provided. 
Their future life, even if they are perfectly restored, 
will be more or less clouded by the fact of having been in 
an asylum. 

Many complaints have been made against the p 
practice of requiring the male patients to dry themselves 
after coming out of a bath on used sheets which have been 
slept on for a week or more. This practice has prevailed 
for many years in this Hospital and was continued until 
the beginning of the year 1920. It should not be allowed 
to be introduced again. 

Another complaint is made which your Commis- 
sioner recommends should be remedied. It is the practice 
of having insane criminals in the same ward with non- 
criminals. As far as possible your Commissioner is of 
opinion that this should be discontinued. 

The specific complaints which came for investi- 
gation were as follows :- 
1. The case of Percy Bowerm an. 

There was a complaint by the patient himself 
that though not insane he was put in this Hospital at the 
instance of his father. As the patient's father was 
present some evidence was admitted. It shewed clearly 

that the patient was properly committed and was manifestly 
insane. He has been in different asylums in Eanada and 
in the United States where he was allowed to go on proba- 
tion. He did not suffer harsh treatment here. There 



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was also a complaint by the father that he was dangerous and 
should not have been allowed out. It was shewn that he was 
allowed out on his mother's application and Inspector 
Dunlop's order on an tmdertakmiig ithat he would not remain in 

Hamilton. 

2. The case of Mary Ann Hoyle at present an inmate of 
this Hospital. 

Her sister Sarah H. Allott attended and claimed 
that this patient who is her sister is not insane. In 
her evidence she said she does not complain nor does 
her sister the patient complain of any bad treatment of 
any kind. The case was therefore dropped. 

5. Frederick 0. Park : 

This patient, a young man, was committed to 
this Hospital on the 17th August 1917. He was suffering 
from Gerebro-spinal syphilis in an advanced stage. He 
was thirty- two years old. His father is a physician. 
He was a returned soldier, returned in 1917. When in 
this Hospital he could not talk rationally and in fact 
could hardly talk at all and it appeared doubtful if he 
recognized his relatives on all occasions. He was 
removed to a private asylum in Guelph and from there in 
September 1918 he was transferred to the Military Hospi- 
tal in Hew Market where he died shortly after. 

This patient at one time while in this Ontario 
Hospital at Hamilton had a cut on his head. Later 

his right eye was black as from a blow, .later his left 
eye was in the same condition and later he had a black 
and blue mark on his right side just below his arm said 



to have been about eight inches square. 



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Park's father and brother seeing these bruises 
and the break in the skin on his head thought he was 
being abused by the attendants. The cut on his head 
and the mark on one of his eyes were satisfactorily 
accounted for by accidental falls. The patient's 
father understood him to say that "Alec did it", in 
answer to a question as to how he got a black eye. Alec 

Stewart was one of the attendants. Stewart is now working at 

a factory in Hamilton 
and attended and in his evidence said he never struck 

Park. Dr. Barnes from the Guelph private asylum and 
Dr. Jaffray from the Hamilton General Hospital, who had 
made an examination of this patient's blood, both said 
he was violently resistant and had to be fed, put to bed 
and taken out of bed, by force; that pressure of the hand 
would bruise and mark his flesh as would also a slight 
knock against anything in his condition and a break in 
the skin v/as easily caused and would not heal. Dr. Web- 
ster, to whom the patient's father spoke of these bruises, 
investigated the matter with Dr. English and they con- 
cluded that there was no reason to suppose they were due 
to ill-treatment and they were satisfied he was being 
treated carefully and properly. 

Your Commissioner is of opinion that this patient 
was not ill-treated by the attendant. 

I slay Chalmers Smith . 

This man was a patient in the Hospital for ten 
months and is now out. He us under the impression he 
came to the asylum of his own accord as he was suffering 
from nervous breakdown and there was no better place to 
go. His complaint is that he v/as "treated too much 
like an insane person". He said the food was good, that 



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he did not get enough outdoor exercise, that he v/asnot 
exactly ill-treated though an attendant once either 
struck him or pushed him to go upstairs, but did not 
hurt him at all* The facts are that he was regularly- 
committed to the asylum on the certificate of two physi- 
cians and the Police Magistrate and the Inspector's 
warrant, he did not come voluntarily but was brought by 
the police. He was in the habit of hiding behind doors, 



etc. 



Smith swore that he saw Alec Stewart, an atten- 



dant, strike a patient named Denton, knocking him down and 
kicking him, that he also saw Stewart .knock a patient 
namedPiper dntfn and kick him when he was down, and that 
he saw a patient named Lunt with a black eye which he 
understood was caused by a blow given him by Stewart. 
These patients were all he said violently dangerous, 
fighting patients. 

Stewart was subpoenaed and gave evidence on 
these charges. He said he had no trouble with Smith and 
that he never had any trouble with Denton, He admitted 
that he had struck Lunt, and he said he did it in self- 
defence as Lunt attacked him in the bathroom and he had 
to fight to save himselJ , He said Piper was a much larger 
man that he is and attacked him and he was forced to fight 
him to save himself. Stewart is not now employed at the 
Asylum. 

It is also true that an attendant, named William 
Glover, who is still an attendant in the refractory ward 
struck Lunt, knocking him down and kicked him when down. 



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It was on an occasion when Glover was removing Lunt from the 
dining-room where he had hit another patient and started a 
fight. Glover's excuse is that Lunt tried to turn back: 
and get into the dining-room again and he (Glover) "lost his 
head". He says it is the only time he ever struck a patient 

Your Commissioner finds that it is true as charg- 
ed that these two attendants, Alexander Stewart and William 
Glover, did strike and kick patients as charged. It is 
also the fact that none of these acts of violence were 
reported to the officers in charge. 



5. 



1.IRS. DOY/RIE'S case. 



This complaint is that she was declared insane 
by collusion between her husband and two doctors. As she has 
no complaint to make as to her treatment in the Asylum no 
investigation was had in her case. She is now out. 



6. 



GEORGE WILLIAM HAZE1L case. 



There was no formal complaint in this case but 
the facts were of such a nature that it was considered well 
to hear evidence. This man died suddenly in an epileptic 
fit and was buried before notice of his death was given to 
his wife. The body was disinterred, the coffin opened, and 
he was seen and identified by his widow. The Inspector had 
the body re-buried according to the wishes of the widow. 
All the expenses of the funeral were paid by the Bepartment 
and the widow and friends expressed satisfaction. Evidence 
was taken at considerable length and accounted in a satisfac- 
tory manner for the unfortunate occurrence. 



7. 



MAR&ARET H. McFARLAllE case. 



An anonymous letter was received in this case 



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complaining only of food and of the work she was required to 
do. These complaints proved to have no foundation in her 
case. 



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CHARLOTTE HOLLXDAY case. 



This ex-patient complains that she was put in 
the asylum by conspiracy of leading doctors and officials in 
Orangeville, though she was not insane. There is no doubt 
but that nae was insane and from the nature of 1ib.e many 
charges of cruelty to other patients by nurses above suspicion 
of anything but kindness to patients her sanity may still be 
doubted. She said the nurses always threw female patients 
on their backs and dragged them along the floor by their 
hair when they wanted to move these patients around. The 
evidence clearly established that her charges were false, 
though she very possibly believes them herself. 

Your Commissioner has not the least difficulty 
in arriving: at the conclusion that her testimony cannot be 
seriously considered in any case she mentioned. The 
evidence of many persons puts this beyond doubt. 



9. 



ELIZABETH SINCLAIR 



case. 



There was no complaint here for investigation. 



10. JAI.IES SCOTT Case. 

There is no thin?: to report in this case. 



11. 



JOHII AIIDER30K Case. 

This is a returned man who was in this asylum 



on different occasions. He escaped once. He speaks of his own 
treatment as good upon the whole, excepting that he did not 



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get enough out-door exercise. He was in during the war, 

and he says an attendant named W. Beaumont in the summer 
or autumn of 1917 knocked him down in a contest about 
possession of a new pack of cards. He says Higgins, 
another returned soldier, interfered and stopped Beaumont. 
Anderson says he was not "badly hurt by the blow and he did 
not speak of it to any one. 

Your Commission^ is of opinion Anderson's story 
is correct as to this matter. He says Beaumont asked him 
not to complain and he did not. Beaumont was dismissed. 

He gave evidence as to brutal treatment of a 
man named Jack Forbes, which one v/ardell, an attendant 
since dismissed, told him had taken place. The statement 
made by V/ardell was proved untrue and the case was satis- 
factorily explained. All the attendants on this ward 
are gone and not available as witnesses, excepting Percy B.- 
Lamb who was then supervisor of ward 8 and says the story 
told by War dell to Anderson was entirely false. 

The most serious matter attested to by Anderson 
was the brutal treatment, according to witness, of a 
"red-headed foreigner" whose name he cannot give. This man 
is said to have goneback to Russia. This is described in 
great detail by Anderson and is of such an outrageous nature 
that it could not have taken place without coming to the 
knowledge of all the officials, superintendent and all, and 
yet no such case as he describes came to their knowledge. 
It is contradicted by Chief Slater and he, Dr. Webster and 
Dr. English swear it could not have taken place as des- 
cribed without coming to their knowledge. One witness was 
under the impression the foreigner had died since, but 
that is a mistafce. It is one of the most extreme charges 
of brutal treatment which came to the knowledge of the 



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G. V/. Y. A. It lacks corroboration and the impossibility 
of its occurrence without discovery is proved. It is a 
case of mental derangement in which many patients in the 
asylum imagine they hear and see things that have no ex- 
istence in fact. 



12. 



JOHN HENBY ANDERSON Case. 



There is nothing in this caee to report. 



15. 



WILLIAM RICHARDSON Case. 



Thxs is not a case coming within the scope of 
this investigation. Mrs. Richardson complains that she and 
her family have suffered great hardship by reason of the 
improper sale by the Department of her husband f s farm. 



14. 



THOMAS SIDNEY KINGDON Case. 



This returned soldier went Overseas in 1916 
and returned in March 1918. He was regularly committed 
to the asylum but he had been confined in the common Gaol 
for twenty-six days before being taken to the asylum. 
He was in the asylum from 12th F ebruary 1919 until 29th 
April 1919. He was then let out on probation and has been 
out ever since. He said "personally I had no complaint 
as to my treatment while here, hut I have seen some pretty 
bad beatings up". H e mentions the case of Solomon 
Clayman, who Kingdon says was terribly pounded and "beaten 
up" by James LIcDonald and one Norton,, two attendants, the 
latter not there now. H e gives an incredible account of 
these two attendants pounding this patient Clayman for a 
long time, over fifteen minutes, because he would not eat. 
He said he heard Clayman died three or four days after 
and he added "I am convinced that the beatings he got 









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causeu his death". Although Kingdon says he saw all this 
done he did not interfere or report it to any one. King- 
don also gave evidence of Jack Stewart, a patient, having a 
black: eye, which he suspected an attendant named I! or ton 
gave him. Kingdon did not see it done, nor does he say 
any one told him Ilorton did it. Norton is not there now, 
nor available as a witness. - 

ilorman Hamburg, a patient at the same time, was 
called to corroborate the dayman charge. His evidence 
is of such a nature that it is unbelievable. Hamburg also 



neither interfered nor reported to any person 



A great 



amount of evidence was given on these two cases. 

The evidence of Dr. English, Chief supervisor of 
attendants Slater, James LIcDonald the attendant, Etta Tully 
a nurse, John Carroll a supervisor whenClayman was there, 
Mrs. Elizabeth Stewart and Mrs. Sophia Morris, clears up 
these two cases and prove facts which account for Kingdon 1 s 
impression of what happened in each case. dayman made 
determined efforts to commit suicide by pounding his head 
on the floor and walls to knock his brains out. These 
efforts were defeated by various devices used in such 
cases. He died a natural death from his disease and not 
from blows or violence. 



15. 



LORA MAY ROGERS Case. 



Nothing was proved in this case requiring comment. 
The complainant was served with a subpoena to attend this 
investigation and was paid her railway fare to Hamilton and 

return and her witness fees. She said she would not attend 
and she did not. She followed the man who served the sub- 
poena and paid her the money to the Railway station and 



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tried to induce him to take the subpoena and the money 
from her hut he refused to do so. The case was satisfac- 
torily explained by the evidence given. 



16. WILLIAL1 A. WILSON Case. 

This is a returned soldier. He had a bruise on 
his shin which he told his wife was caused by an atten- 
dant kicking him. Mrs. Wilson spoke to Dr. Webster 
about this. He is described as a dangerous irritable 
patient and at times has to be restrained by force. 

Dr. English and Dr. V/ebster investigated this complaint 
and came to the conclusion that the attendant had not 
kicked him but that he had got the bruise by accidentally 
striking something when being restrained when in one of 
his violent fits. His wife says she does not like 
leaving him in Ward 8, the refractory ward. She says he 
is not very insane now but that he cannot be given his 
liberty or he will* wander away aimlessly. She says she 
thinks he will become quite insane if kept where he is 
and he thinks the same. She, like many others, thinks 
a returned soldier should be in a place specially suited 
to his condition and not in an insane asylum. 

17. JOHN HEWS OH Case. 

This man is an ex-attendant and made one charge 
of abuse of a pateent which the evidence proved satis- 
f actor ily was not true. His statements were in your 
Commissioner's opinion to a certain extent animated by 

a desire to "get back at " an attendant. 

H e complained that the the rations were cut 
down at one time and he also complained of requiring 



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the male patients to dry themselves after their bath on 
sheets taken off the beds after having been used a week 
or more. Both of these complaints have been remarked 
upon in the early part of this report. 



18. 



Mis. EDITH I. PARISH 



Case. 



This woman was a patient in this Asylum. S'jje 
was regularly admitted on the 23rd of May 1914 and 
finally discharged on 9th October 1918. She had been 
confined in an Asylum for the insane in England. She 
made many charges in a letter to the G. W. V. A. and in 
an affidavit of ill-treatment of herself and patients, 
and of insufficient use of disinfectants in cases of 
typhoid fever patiBjlfcs and in a case of erysipelas . 
She was subpoenaed and paid her railway fare and witness 
fees but she refused to come. Every effort was made to 
secure her attendance. She threatened to hare her 
solicitor get an injunction to stop the investigation 
of the charges she had made. It was proved by convinc- 
ing evidence that many of her statements were false and 
others grossly exaggerated. 

The representatives of the G. W. V. A. after 
hearing and seeing some of the witnesses called said 
they were convinced that no reliance could be placed 
on her statements and suggested that it was unnecessary 
to continue the investigation of them. 

Your Commissioner, however, at request of 
Counsel and of the Superintendent heard evidence offered 
as to ivi rs. Parker's history and as to all her complaints. 



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-20- 



Your Commissioner at the request of the Great 
War Veterans forwards in connection with this report the 
very excellent report and suggestions which they make as the 
result of their observations and of their opinions formed 
from the evidence, statements, explanations and discussions 
which took place at the investigation. 

Your Commissioner in the early part of this 
report dealt with some only of these matters recommended 
by the Great War Veterans Association before he had the 
opportunity of reading their report. 

Your Commissioner now desires to add that he 
approves of the first, second, third, seventh, sixteenth 
and the first part of the eighteenth recommendations which 
they make. Of the others some are now in practice while 
of others your Commissioner does not feel in a position to 



speak 



Your Commissioner desires to express his 



appreciation of the skilful, fair and persistent work 
of Mr. S. F. Washington E. C. in conducting the examinations. 
To his efforts and the valuable assistance given him by Messrs 
Fred V/. Tresham and Dugald Mclean representing the Central 
Branch G. W. V. A., Mr. Frank Bryant representing the East 
End Branch G. ./. V. A., Messrs John Fish and Hugh Arnold 
representing the Mount Hamilton Branch G. »/. V. A. and by Mr. 
J. L. Counsell engaged by the G. W. V. A. to assist Mr. 
./ashington, is due the securing and fair and full presentation 
of all available evidence on the various charges, complaints 
and matters which were investigated. 

All of which together with a copy of the evidence taken 
your Co^rrassioner has the honour to respectfull;; submit. 
Dated this 1st Day of March A. D. 1920. 




Cor;;;rissioner . 












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